Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in all fourteen client records reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Authorization to Use or Disclose Health Information form (consent form) is being modified by our Medical Records Documentation team to include a space where it can be indicated if the client accepts or rejects a copy of the document. It will read: Client accepts copy____
Client rejects copy_____
This change will be made no later than October 31. Following the implementation of this change, a brief training with will be held to go over the new addition and change in process for what should occur when a client accepts or a rejects a copy of the document. This training will be given to therapists, case managers, interns, nursing staff, and admissions staff.
Additionally, compliance performance of this new addition and change in process will be actively monitored and audited each month as part of our Quality Assurance and Performance Improvement (QAPI) program. Monitoring and audits will occur for at least three months to ensure compliance.
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